An Influenza Pandemic Planning Guide for Homeless and ...

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An Influenza Pandemic Planning Guide for Homeless and Housing Service Providers

Seattle-King County, Washington

Acknowledgements

Development of this guide was made possible with support from the Preparedness Section of Public Health - Seattle & King County and the Vulnerable Populations Action Team. Much of the information in this guide was originally developed by Public Health's Communicable Disease Control, Epidemiology & Immunization Section. Public Health expresses its appreciation to the following individuals who offered their time and expertise to help shape this guide:

Heather Barr, RN, Public Health-Seattle & King County, Health Care for the Homeless Network Dale Bergquist, Bread of Life Mission Karyn Boerger, Downtown Emergency Service Center Rosa Bradshaw, Seattle-King County Coalition on Homelessness, and Fremont Public Association Fred Bryant, Sobering Support Center, Recovery Centers of King County David Coffey, Recovery Cafe Nancy Cole, Plymouth Housing Group Marci Curtin, Friends of Youth Nance Daiker, Angeline's, YWCA of Seattle-King-Snohomish County Jeff Duchin, MD, Communicable Disease Control, Epidemiology & Immunization Section, Public Health Jenny Filion, Public Health-Seattle & King County, Health Care for the Homeless Charissa Fotinos, MD, Medical Director, Public Health-Seattle & King County Bob Goetschius, St. Martin de Porres, Archdiocesan Housing Authority Gary Goldbaum, MD, Senior Medical Epidemiologist, Public Health ? Seattle & King County Jenine Grey, Chief Seattle Club Ellen Hurtado, Compass Center Onora Lien, Public Health-Seattle & King County Dan McDougall-Treacy, Valley Cities Counseling & Consultation Arlene Oki, City of Seattle Human Services Department Sandy Olson, Pioneer Square Clinic, Harborview Medical Center Stacey Peterson, Community Psychiatric Clinic Lewis Rubinson, MD, Disaster Medicine Director, Public Health-Seattle & King County Marcia Stone, RN, Public Health-Seattle & King County, Health Care for the Homeless Nancy Sugg, MD, Medical Director, Pioneer Square Clinic, Harborview Medical Center Sala Sweet, Plymouth Housing Group Michael Van Lydegraf, Bread of Life Mission Jim Vollendroff, King County Mental Health, Chemical Abuse & Dependency Services Division Meredith Li-Vollmer, Public Health-Seattle & King County Janna Wilson, Public Health-Seattle & King County, Health Care for the Homeless Network Terrie Yaffe, Seattle-King County Coalition on Homelessness, and Child Care Resources Diane Young, Public Health-Seattle & King County

Finally, our special thanks to Toronto Public Health for sharing their planning guide for homeless programs, and for allowing us to base this guide upon their work.

Disclaimer: This Planning Guide is a tool to support planning for pandemic influenza in the homeless and housing service sector. Public Health-Seattle & King County is not responsible for any misinterpretation or misuse of the contents of this guide.

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Table of Contents

1. Introduction: Purpose of This Guide.............................................................................................4 2. Pandemic Influenza Information & Why Homeless Service Providers Should Be Concerned ....5 3. Preparedness Roles & Resources...................................................................................................9 4. Homeless and Housing Service Providers: Before, During, and After a Pandemic ...................12

4-a. Develop or review infectious disease protocols, policies, and procedures........................13 4-b. Train staff and clients on routine practices for infection control ......................................13 4-c. Learn, establish, and practice an "incident command" system..........................................13 4-d. Stockpile supplies ..............................................................................................................14 4-e. Food practices and access ...................................................................................................15 4-f. Support ill individuals ........................................................................................................15 4-g. Deaths on site......................................................................................................................18 4-h. Considerations for outreach clients and outreach workers.................................................19 4-i. When homeless service agencies become overwhelmed and face possible closure ...........20 4-j. Staff staying on site ............................................................................................................20 4-k. Reduce client mobility.......................................................................................................21 4-l. Other issues of concern ......................................................................................................21 4-m. Issues requiring further community-level planning between homeless service agencies

and health system..............................................................................................................22

Appendices Appendix A: How to Care for Someone with Influenza..................................................................24 Appendix B: Preventing the Spread of Influenza ............................................................................26 Appendix C: Glossary......................................................................................................................28

Please direct questions or comments regarding this guide to: Health Care for the Homeless Network Public Health?Seattle & King County 999 Third Avenue, Suite 900 Seattle, WA 98104 (206) 296-5091 health/hchn hchn@

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1. Introduction: Purpose of This Guide

The purpose of this planning guide is to help Seattle-King County homeless service agencies-- including shelters, day programs, housing programs, and others--prepare for an influenza pandemic. This planning guide:

? Provides information on influenza, what homeless agencies can expect, and where to get more information. Outlines Public Health--Seattle & King County's (PHSKC) role during an influenza pandemic.

? Lays out issues of special concern for homeless service agencies on pandemic flu preparation and response, and offers initial guidance.

? Identifies areas for future discussion and planning.

? Encourages organizations to start incorporating new practices in their day-to-day operations now that will help them during an influenza pandemic or any other emergency.

Every organization must plan for the specific disruptions it may face during an influenza pandemic. The overall goal of planning is to reduce illness (morbidity), death (mortality), and social disruption resulting from an influenza pandemic. Although this guide identifies specific issues associated with pandemic influenza, much of the information applies to other emergencies as well.

Agencies that provide services to homeless are very diverse. Congregate shelters, apartmentstyle shelters, voucher programs, and low-income housing programs all have very different ways of providing clients with a place to stay. Programs that offer homeless people other services include hygiene centers, employment agencies, drop-in centers, mental health programs and meal programs. They all provide services to a wide variety of clients, and operate under different organizational and funding structures. This planning guide is intended to support the planning process all homeless service agencies need to undertake to address the challenges that an influenza pandemic will present. Each agency will need to adapt and think about these issues based on their clients, staffing, and site(s).

This guide will change and be updated over time. This planning guide is an evolving document. As planning continues at the federal, state and local levels, will update it to add, change, and delete information. There is a lot we don't know about influenza pandemics, and when the next one occurs we will learn as it unfolds. Consequently, guidance may need to be revised and new recommendations issued. Look for the most current guidance on the Public Health website, below.

Subscribe today to receive pandemic flu e-mail updates directly from Public Health-Seattle King County.

As a subscriber, you will get e-mails alerting you of significant updates posted to the Public Health's pandemic flu website. To sign up, go to:



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2. Pandemic Influenza Information & Why Homeless Service Providers Should Be Concerned

Please visit:



for basic facts on pandemic flu and links to more information.

What is pandemic influenza?

Influenza viruses primarily cause infections of the respiratory tract (breathing tubes and lungs). In some persons, complications of influenza can be severe, including pneumonia. Pandemic influenza is a global outbreak of disease from a new influenza A virus that is unlike past influenza viruses. Because people have not been infected with a similar virus in the past, most or all people will not have any natural immunity (protection) to a new pandemic virus.

? Pandemic flu may be more severe, affect more people, and cause more deaths than seasonal influenza. It is not possible to predict in advance the severity of a future influenza pandemic.

? Once a pandemic virus develops, it can spread rapidly causing outbreaks around the world.

? If the pandemic virus causes severe disease, many people may develop serious illnesses. Some of those who develop severe influenza will die.

? There is no vaccine available at this time for a pandemic flu, and it is expected to take approximately six months after a pandemic flu appears for the first doses to be manufactured and significantly longer before there is an adequate supply for the public.

? It is not possible to predict accurately when influenza pandemics will occur. However, the current outbreak of avian influenza in Asia, Europe, and Africa has influenza experts concerned that a pandemic is developing that may be severe.

? In King County alone, it is estimated that a severe pandemic flu could result in over 540,000 people ill, 270,000 needing outpatient medical care, over 59,000 requiring hospitalization, and up to 11,500 could die.

? High levels of illness and death during a pandemic could lead to other forms of social and economic disruption. With many people in so many places becoming ill, short supplies of staffing may occur across the community, including for medical organizations, government, non-profit organizations, and many critical businesses.

? Impacts of a pandemic on everyday life may include school and business closings, the interruption of basic services such as public transportation and food delivery, and cancellation of large public gatherings.

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How Does Influenza Spread?

Knowledge about the spread of influenza viruses is based on seasonal influenza. It is likely the same routes of spread will apply to a pandemic influenza virus. Influenza viruses spread from person to person through close contact. Transmission occurs through several routes, including large droplets and direct and indirect contact. Airborne transmission may also occur over short distances, but this is not known with certainty.

? Droplet spread occurs when relatively large respiratory droplets produced by sneezing, coughing, talking or singing come in contact with another person's eye, nose, or mouth. These droplets may spray approximately one meter (about three feet). Droplet transmission is thought to be the major route of transmission for seasonal influenza.

? Airborne transmission results from inhalation of smaller infected droplets that spread through the air, for example when an infected person coughs forcefully, and may occur over short distances (three ? six feet). The role of short-range airborne transmission in the spread of influenza is not known, but is possible.

? Direct contact occurs when there is direct transfer of the virus through skin to skin contact or kissing. For example, an infected person may cough into his or her hands and then shake hands with another person who may then touch his or her own eyes, nose or mouth.

? Indirect contact occurs when objects or surfaces contaminated with the secretions of an ill person are touched by another person and brought to the eyes, nose, or mouth.

How long does influenza remain on surfaces? Limited information suggests that influenza viruses survive for 24-48 hours on hard, nonporous surfaces such as stainless steel and plastic but for less than 8-12 hours on cloth, paper, and tissues. Influenza A virus can be transferred from stainless steel surfaces to hands for 24 hours, and from tissues to hands for up to 15 minutes.

How long are people infected with the pandemic flu virus infectious? People infected with influenza are considered able to infect others beginning 1 day before symptoms develop and up to approximately 5 days after becoming sick. That means that an infected person may be able to pass on the flu to someone else before they know they are sick, as well as once they become ill. People are most contagious at the beginning of the illness, and persons with weakened immune systems and young children can be contagious for a longer time.

Why Homeless Service Providers Should be Concerned about Pandemic Flu

Impact on Health The severity of illness and the death rate may be similar to a usual influenza season - or may be

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much more severe. It may be anticipated that homeless people are at greater risk of becoming sick with the flu in the pandemic because:

? Homeless people live in more crowded conditions. ? Homeless people suffer from a variety of chronic and acute conditions which may affect

their immune system response. ? They also suffer from addiction and mental illness in rates disparate from the general

population, and may have problems following advice. ? They may not seek care (and isolation) until they are very sick. ? Social distancing will be difficult to achieve.

Impact on Daily Living

Important community services may need to be curtailed, consolidated, or suspended because of widespread absenteeism in the workplace. This will impact all residents of King County, but may have a greater impact on homeless people.

? Businesses may reduce their hours or close for a prolonged length of time. Working homeless people may not have sick leave and vacation benefits; the financial impact on the working homeless and working poor could be very hard.

? Medical facilities and emergency services such as fire, ambulance and police may also be overwhelmed by demand and therefore slow to respond. They might change the level of care they usually provide.

? Public transportation may be limited or unavailable. Poor and homeless people who rely on public transportation may be affected.

? Community activities may need to be curtailed or cancelled to prevent the spread of infection. Homeless people who rely on food banks, feeding programs, churches and libraries may have to make major adjustments to their routines.

? Restaurants, bars and coffee shops may close. Many homeless people use these businesses during the day when many shelters are regularly closed.

? Supply chains of resources (food, pharmaceuticals, fuel, etc) for every sector may be disrupted.

? Homeless people and those living on society's margins often have a limited safety net. They may not have anyone to go to the store for them or give them simple home care if they get sick.

? Homeless people who do not tend to access services may be forced by sickness and paucity of supplies to seek help at your agencies. This increased demand will impact your regular users and your staff.

? Homeless people may have limited access to information from the mainstream media (or may not trust or understand what they hear), and may be relying on trusted agency staff and case managers for information.

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Impact on Emotional and Mental Health Physical illness is not the only effect of a large scale health emergency, including an influenza pandemic. The psychological impact on the public will likely be significant. Homeless people enduring mental illnesses may lose continuity of care for an undetermined period of time. They may run out of medications. They may miss the comfort of regular contact with case managers, counselors and friends or family members who may be sick. Homeless people will also deeply feel the loss of any friends or caregivers who may die in the pandemic. Staff will be under much additional stress. They will be worried about their clients, about decisions they must make for and about clients, and about the efficacy of the system and their role in it. They will be concerned about their own health, the health and safety of their families, and their finances. All people affected by a disaster, such as a pandemic, must adjust to major changes in their lives. People may be grieving for friends or family members and may have to deal with personal or family crises. Many people will need to talk about their feelings and experiences and learn how to face the challenges of an unknown future.

Impact on Employee Absenteeism The Centers for Disease Control and Prevention estimates that 15 to 35% of the population will become ill during the course of a pandemic and will be unable to work for a period of time. Many people who are not ill may stay home to care for children, other family members, or friends who are ill. Some people may stay home due to concerns or fears about potential exposure to influenza in the community and in the workplace. The resulting high rates of employee absenteeism will affect every sector and probably every homeless service agency.

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